After reading the first part of this post, you may wonder what will be a solution for the “problem” of screening these type of patients.  Well, I don’t have a perfect solution but here are 3 ideas to keep in mind.

1. I am a huge advocate of examining the patient in terms of an arthrokinematic, osteopathic approach.  You can read prior posts on this topic here and here.

I find joint/soft tissue dysfunctions and then make a clinical judgment if it is the pain generator and reproduces the patient’s concordant symptoms.  This usually can be made immediately and agreed upon with you and the patient. However, you do have to keep in mind that medical conditions outside our realm may mimic these musculoskeletal dysfunctions.  I have no data on the percentage but needs to be considered.  You just want to keep this in mind as cause-effect relationship from the treatment does not 100% correlate with a mechanical disorder.  Nevertheless, response to conservative care is huge.

2. Of course, the entire patient medical history has to be considered.  Are other red flags flying high?  You can access Leerar et al article here.

-History of CA in family, high blood pressure, immune suppression, long-term corticosteroid use, smoking, major trauma, minor trauma (elderly)

-Age > 50 y/o or age < 20 y/o.

-Constitutional symptoms: fever, chills, unexplained weight loss

-Bowel/bladder incontinence, saddle anesthesia, asymmetrical neurological findings (sensory or motor)

3. Some things we should ask if night pain is present:

1. Is it the most severe time of the day.

-I would ask this alongside if the pain is constant.  Both of these should warrant referral.

2. If it does wake you, how many times a week does this occur?

-The more nights worries me.  It just doesn’t mean the patient had a bad night of tossing and turning.

3. What do you do to go back to sleep? Or, are you able to go back to sleep?

-Changing positions is huge with this question.  If they are able to go back to sleep, much less worry to me.

Bottom line:

We shouldn’t be overly concerned with simple night pain as a red flag.  Even if a patient states the pain is constant, I would get a pain rating scale on different postures/activities.  More often than not, the numbers will be different.  Some patients may just “say it is constant”.  You know what I mean by this.  If the pain rating is different, this will show that the pain changes based on the mechanical load on the spine, which usually demonstrates a mechanical origin. 

The best predictor in my opinion is the response to conservative care.   If you are not seeing a typical improvement based on the symptoms and irritability, it would be best to refer on as necessary.

As always, I will entertain your comments and questions.

Ross MD, Boissonnault WG.  JOSPT.  Guest Editorial. Red Flags: To Screen or Not to Screen? 2010; 40(11); 682-684.

Biering-Sorensen F: A prospective study of low back pain in a general population. Scand J Rehabil Med 15:81-88, 1983.

Farrel JP, Twomeny LT: Acute low back pain: Comparision of two conservative treatment approaches. Med J Aust 1(4): 160-164, 1982.

Jayson MI< Sims-Willaims H, Young S, Baddely H, Collins E: Mobilization and manipulation for low back pain. Spine 6(4): 409-416, 1981.

Roach KE, Brown M, Ricker E, et al.  The Use of Patient Symptoms to Screen for Serious Back Problems.  JOSPT. 1995; 21(1), 2-6.

Leerar PJ et al.  Documentation of Red Flags by Physical Therapists for Patients with Low Back Pain.  J Man Manip Ther. 2007 (15)1; 42-49.

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